The patient is admitted to general medicine. The primary team consults medical oncology and radiation oncology. An EEG is able to be obtained shortly, with results listed below. An MRI has been ordered but not yet scheduled.
Medical oncology recommends high-dose dexamethasone. Radiation oncology recommends obtaining the brain MRI-- mainly to help better evaluate whether she's experiencing pseudoprogression as a result of her immunotherapy, but perhaps also the degree of her leptomeningeal disease.
There's a lot of abnormal focal activity-- delta slowing, specifically. This signifies focal neuronal dysfunction. For this patient, the frequent right frontotemporal delta slowing is secondary to her prior right frontal region where her metastasis existed and was resected. There are no clear epileptiform abnormalities, and the report makes no mention of any evolution of the rhythmic delta slowing, which is reassuring. (However, this doesn't indicate that she hasn't had prior seizures. Again, it's important to contextualize this test (and others) and factor in your pre-test probability.) The abundant generalized delta activity is non-specific and correlates with what we know about her mental status being abnormal.
As a consultant, the degree to which you'll follow along is dictated will vary by the patient's clinical situation and the primary team's experience and comfort level. For patients like this, on whom you operated before, you may be more hands-on if the active issue is very related to your surgery. Otherwise, you may simply answer questions that are posed and then move along. For this patient, she has something going on neurologically, but it doesn't seem too related to that resection in which you were involved. (At least, the EEG didn't show any epileptiform findings there, and even if it did, well, neurology is already managing that.) Medical oncology is managing her steroid dosing and that's fine for now-- they originally recommended it themselves.
There was no surgical intervention when you were originally consulted, and still not now. Thus, you probably don't need to follow closely. It's important to note, however, that the patient has leptomeningeal disease (LMD). That may already start influencing how you think about her candidacy for any future neurosurgical interventions. LMD is typically managed medically and not surgically, however, so you don't currently see a future role for any curative intervention. They can call you back if oncology recommends a reservoir placement for intraventricular oncologic therapies.
Since we don't need to take a very active role, we should be explicit with what should trigger the primary team to call us back. It's helpful to educate primary teams about things that we find concerning and about which we want to know. So, if they decide if they want therapeutic anticoagulation (prophylaxis is fine from our standpoint because it's been a long time since her surgery and there's no acute bleeding), they can ask for formal recommendations. If they experience a neurologic decline, they should obtain a STAT non-contrast head CT and call us. They should definitely call us if the patient ends up developing an intracranial hemorrhage. Anything else we should warn them about?
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